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Risk for hemorrhage,infection,thrombus formation, neuromuscular
impairment/loss of limb
N.I.'s to prevent the above:
Frequently inspect insertion site, for local signs of inflammation,if
bacterial infection-suspected, remove line and culture tip.
Pt on heparin -coughing up blood.Initial nursing action
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Hold med
,Why give ASA , mechanism of action?
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Anti-plat-prevent formation of clots.MI-there is occluded arteries, which
could cause stasis of blood and even dislodging of clots.
Pt has a chest tube, rise and fall ,water seal system, correlates to pt respiratory rate,
what is the app nursing action?
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Nothing, that is normal.
pacemaker insertion-pt teaching? post and pre
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Informed consent
Prepare skin
educate about type of pacemaker
Post:
temp pacemaker: controlled facility for tele
Permanent pacemaker:D/S teach:
Carry ID
Wear sling/ do not raise arm for 1-2 wks
Take pulse daily same time
Report dizziness,fainting,fatigue,weakness,cp
Weight gain
ICD device-shock-ppl next-feel it
LOC occur prior ICD shock
Resume sexual activity-avoid positions put stress on incision site
, No items in magnetic field-garage door,strong magnets, gennies
NO MRI/CT
Inform airport security
Acute hypoxemic Resp.failure: Initial first sign ?
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Change in mental status-ALOC
Occurs early- brain sensitive to O2 changes
Purpose of heparin for non-stemi MI?
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Prevent clot formation
What cardiac enzymes specific to cardiac damage
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Troponin
Stemi vs Non-Stemi Interventions
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